Nurses, Primary Care & Shortage Designation

HHS Sec. Kathleen Sebelius was at Duke on Monday announcing a program funded by the ACA to train more advanced practice nurses to expand the supply of primary care providers. The role of nurses in primary care figured heavily in the attempts by the negotiated rulemaking committee created by sec 5602 of the ACA to redefine the HPSA and MUA methods that are used to make areas eligible for federal monies designed to ameliorate provider shortages and/or underservice.

The most radical aspect of the proposal that we approved 21-2 is the “counting” of non physician primary care providers in the calculation of a population to primary care provider ratio.

Counting Providers: The Committee’s proposal recognizes that nurse practitioners,physician assistants, and certified nurse midwives provide significant primary care services in our Nation. Therefore, for the first time, these clinicians will appropriately be included in the count for purposes of developing the population-to-provider (P2P) ratio.

The current designation methods–essentially unchanged since the mid-1970s–do not include non-physician providers in the supply of primary care. Deciding to count non physician providers was one step, but the next was at what weighting relative to what type of physicians?

We counted primary care Nurse Practitioners, Physician Assistants and Certified Nurse Midwives at 0.75 FTE, along with physicians (MDs and DOs) in primary care specialties, defined as General Practice, Family Practice, General Internal Medicine, General Pediatrics, Geriatrics and Adolescent medicine counted as 1.0 to develop a total primary care supply measure for a service area. Certain providers were “backed out” of counts, such as those completing National Health Service Corps placements.

There is a variety of evidence base on which to make some of these judgments, but there are plenty of subjective and political decisions lurking just below the water. For example, advanced practice nurses have long been key providers of primary care in rural areas, so “counting” them as primary care providers seems obvious to many (most) persons who look at the evidence. However, by doing so, you place rural areas at a disadvantage by increasing their “supply” of primary care and making them less likely to be designated as a HPSA, that makes them eligible for resources. This put those who were often in a coalition (rural advocates and nurses) at odds on this issue because they now had different perspectives (impact on designation v. professionalism).

This is only one such issue. There are many others, which is why both the Clinton and Bush II administrations tried to revise the HPSA and MUA methodologies and failed to do so (they were blown up in the rule making process).

Most anyone looking objectively at the issues realizes that HPSA and MUA need to be updated and changed. Getting an agreement on how to do so is exceedingly difficult.

Rulemaking Committee Recommends New HPSA/MUA Designation Methods 21-2

Last Thursday, the the Negotiated Rulemaking Committee on the Designation of HSPAs and MUAs created by section 5602 of the ACA approved a recommendation to the Secretary of HHS for changes to how the federal government identifies Health Professional Shortage Areas (HPSA) and Medically Underserved Areas (MUA) by a vote of 21-2 (5 members were not present and did not vote). These methods are used to identify areas and populations that are eligible to receive key safety net resources such as National Health Service Corps providers (HPSA) or funds to support Community Health Centers (MUA). The current methods used to designate these areas are largely unchanged since the 1970s.

Under the Negotiated Rulemaking Act of 1990 a recommendation that was unanimous would mean that the Secretary of HHS would have to move ahead with our recommendation verbatim as the draft interim rule, at which point the normal comment process on proposed federal rules would take effect. However, because the recommendation was not unanimous, the Secretary may use our recommendation as guidance but also may propose changes before putting forth an interim final rule. The two members of the committee who voted against the final recommendation both said that they felt as though more analysis was needed in order to finalize the proposed designation methods, and that they believed their no votes provided the Secretary with flexibility to ensure the strongest rule possible. I have a great deal of respect for both of these members and take them at their word, and I understand their position.

I voted in favor of the recommendation because I believe it to be a clear improvement over the status quo, and out of respect for the negotiation process in which the committee had engaged. The final report of the committee, along with dissenting reports, will be publicly available in a few weeks, at which time I will write about the methods we decided upon and the research we considered in formulating a new approach.

Community Health Centers and Resource Allocation

Aaron posted yesterday on the impact of cuts to expanded money for community health centers (CHCs). CHCs have typically been areas of bipartisan agreement, even for those who might be against larger scale reforms, but they were unable to escape cuts to expansions put in place by the ACA in the current political context.

This Wednesday and Thursday will be the final meeting of the Negotiated Rulemaking Committee that is revising the method of designating medically underserved areas (MUA) and health professional shortage areas (HPSA), that are essentially unchanged since the 1970s. Being a MUA makes an area/populations eligible for federal resources such as those enabling the work of CHCs. I know, I know, the September meeting was also supposed to be the last one for this committee, but work expands to fill the time until deadlines (the committee is disbanded as I understand it, on October 31, 2011, so this actually is it). Where things stand:

  • The biggest source of committee disagreement remains the meta-role of such designations. Is it to identify expansively those areas/populations that could be helped by extra resources, or to focus designations on the worst-off areas due to the limited resources available to respond?
  • There is an inevitable triage of areas/populations given finite resources and always has been; the question we are wrestling with is to what degree should this be acknowledged when making areas/populations eligible for such resources?
  • A worry of some is that expansive designation means that better off areas will prevail in the scramble for finite resources. A worry for others is that we should identify those places in which there are groups with access barriers, even if we cannot ameliorate them all.
  • Under the Negotiated Rulemaking Act of 1990 that guides the work of the committee, the definition of consensus is unanimous agreement, and getting there with 28 people is very difficult.
  • If we reach a unanimous agreement, our decisions will become the essence of a draft interim final rule.
  • If we do not reach a unanimous agreement, the Sec. of HHS can move ahead to publish a rule to change these designation procedures in the manner of her choosing, following the normal processes. So, some change in the designation method seems likely.

In any event, this is a big week for our country’s safety net, as the means of designating areas and populations as eligible to receive federal resources such as those provided via CHCs is likely to be changed one way or another by the actions of this committee.


What Is Medical Underservice?

Tomorrow through Friday, the Negotiated Rulemaking Committee on the Designation of HSPAs and MUAs created by section 5602 of the ACA will begin its 11th in person meeting in Rockville, MD. Health Professional Shortage Areas (HPSA) and Medically Underserved Areas (MUA) are used to identify areas and populations that are eligible to receive key safety net resources such as National Health Service Corps providers or funds to support Community Health Centers. The methods used to designate these areas are largely unchanged since the 1970s and need updating.

I am a member of this committee, and we must submit our recommendations to the Secretary of HHS by October 31, 2011; under the Negotiated Rulemaking Act of 1990 any recommendations must be unanimous. Achieving a unanimous recommendation for such a complicated issue is a challenge to say the least. A quick count of my calendar shows that we will have spent around one and-a-half months of work days together since September 2010 and innumerable conference calls in between.

I think that we have managed to get on roughly the same track for considering changes to the HPSA methodology, in large part because we have a shared understanding of what “health professional shortage” means. It has been harder for our committee to agree to a practical definition of “what is medical underservice?” and more precisely, whether designation of eligible areas for resources should define a standard below which no community or population should fall even if the resources to bring this about are not available, or whether we should be identifying the “worst of the worst” right off the bat. Myriad practical issues flow out of this subtle distinction.

I don’t really know how it will turn out, and I have a certain exhaustion about the process at this point. However, as I packed last night for the last meeting, I realized that I will miss seeing these new friends and colleagues once the committee is dissolved. We came together from different perspectives to seek to improve the functioning of our nation’s crucial safety net. Here’s hoping we can reach a compromise this week, and kick the ball down the field a bit for the good of our country.

Allocating resources to underserved areas

I am in Rockville, MD, serving on the HRSA Negotiated Rulemaking committee that is updating the way that the federal government designates Health Professional Shortage Areas (HPSA) and Medically Underserved Areas (MUA). The current designation methods are essentially unchanged since the 1970s. These designations make localities eligible for resources such as National Health Service Corps providers, Community Health Centers and the Medicare Physician Bonus Payment program.

This committee was created by the Affordable Care Act, and began meeting in September, 2010 (today is the 26th day we have met since then!). We are moving toward completing our recommendations that will be submitted to the Secretary of HHS by October, 2011, which will then be put forth as an interim final rule.

As Aaron recently noted, the ACA also created a Health Workforce Commission to look broadly at the primary care needs of the nation and the barriers to training them. However, this group has been unable to even begin its work due to Republicans in Congress blocking funding for this Commission. The work of the two groups is certainly related. The one on which I am serving is an attempt to improve the means of allocating finite resources to those areas and populations with the highest needs and/or most extreme deprivation of providers. The Health Workforce Commission was designed to identify ways to more generally expand the supply of primary care providers.

There are differences between these two groups. The Negotiated Rulemaking Committee on which I serve was created for the discrete task of updating the HPSA and MUA designation rules and it will then disband. Its work was explicitly funded by the ACA, probably due to the short term nature of our work. The Health Workforce Commission is meant to be an ongoing group, acknowledging the longstanding nature of the well known problems of creating the primary care workforce that our nation needs. Its funding is therefore dependent upon the normal appropriation process in Congress. The need for more primary care providers is about as bipartisan a topic imaginable. Even that is now caught up in partisan squabbling.


You can follow links in this post to get the gory details of the previous meetings. Tomorrow and Friday I will link pdf documents in this post that updates our work this week.